Posted by: Thixia | July 5, 2008

MS and the Bowel 5 of 6

 

Bowel incontinence

 

Fewer people with MS experience bowel incontinence than constipation but it can be one of the most distressing MS symptoms. An involuntary leakage from the bowel may be something that happens once only very occasionally, once in perhaps three months, or more frequently. Whatever the frequency, it can lead to huge uncertainty and worry. There can also be an embarrassing inability to control wind. Careful management can, however, help to minimise problems.

 

Causes of bowel incontinence

 

Causes of bowel or faecal incontinence in MS can vary, or may be due to a combination of things.

 

It is thought that one of the most common causes of bowel incontinence in MS is linked to constipation, when stool (faeces) become ‘impacted’ in the bowel and there is leakage around it. Impacted stool becomes very hard and this can irritate the wall of the bowel, causing it to produce more fluid and mucus that then leaks out through the anus (back passage). Because this fluid is stained brown by stools, it can be mistaken for diarrhoea. Most studies have shown that bowel incontinence in MS is associated with constipation, so as a general rule, people with MS who have bowel incontinence but not constipation should be investigated for other lower bowel problems.

 

Another cause may be to do with the anal sphincter muscles and the nerves in the anus. Passing stool from the anus is a delicate and complex process. If MS interferes with the reflex action that is needed, the ability of nerves to sense stool, a person’s voluntary ability to control muscles, or there has been previous damage to the muscles themselves, this process will be impaired. It has been found that people with MS can have reduced ability to squeeze their anal sphincter muscles, for example, and diarrhoea or loose stool is harder to hold if your muscles are weak or you lose your ‘early warning system’.

 

In health, the bowel is normally not active overnight but in some people with long-standing MS, the bowel may empty while asleep at night. This may happen occasionally or regularly.

 

Repeated straining when going to the loo or something unrelated to MS, like a tear during childbirth or surgery to the anus, can also be a cause of leakage as the anal muscles are weakened.

 

Fatigue, general muscle weakness, spasticity and impaired mobility can contribute to problems with bowel incontinence.

 

Like anyone else, people with MS may get diarrhoea through infections, having an upset stomach from eating bad food, from antibiotics or medications.

 

 

 

Managing bowel incontinence

 

You should start by seeking help from a health professional, whether a GP, MS nurse or continence adviser.

 

A thorough assessment

 

A first step to managing bowel incontinence will generally be an assessment of the problem. A thorough assessment will help work out if the problem is likely to be MS or other factors, can assess the extent of any nerve or muscle damage and recommend the best treatment for you.

 

Questions you may be asked:

 

  • When did it start?
  • How often do you open your bowels?
  • Do you have to rush to the toilet?
  • Do you have to strain to empty your bowels?
  • Is it painful to empty your bowels?
  • Are your stools hard, soft but formed, or loose (runny)?
  • Do you ever see blood when you open your bowels?
  • Do you have difficulty wiping clean after opening your bowels?
  • Do you ever lose stool when you walk, or are in bed at night?
  • Do you need to wear a pad?
  • If you are losing stool, how often, how much, what is the consistency?
  • Are you taking any medications?

 

You will also be asked general questions about past operations, childbirth, and your diet and fluid intake.

 

Do any foods or drinks make it better or worse?

 

You might be asked to keep a diary showing when your bowels open in the toilet, when you have a bowel accident, or (if you wear a pad) when you need to change it.

 

Medical staff will examine the anal sphincter muscles but an accurate evaluation of ‘squeeze pressures’ is only really obtained from using an anorectal manometry test, where a small tube or balloon measures pressures in the anus. There are other tests to find structural problems, like tears in sphincter muscles. Endosonography uses ultrasound to scan the sphincter muscles. Defaecography uses x-rays to help medical staff assess the workings of the rectum and sphincter.

 

 

 

Check your diet

 

Advice will vary from person to person. High-fibre foods, caffeine, milk products, chocolate, alcohol, spicy food and artificial sweeteners can have the effect of producing loose stool in some people. Arrowroot biscuits, marshmallow sweets and ripe bananas can help make stools firmer. It is worth experimenting to see if you can identify anything that upsets your control or makes stools firmer.

 

 

A regular and comfortable bowel routine

 

Try to establish a regular routine for going to the toilet. You can plan to be in place at a time when your bowels are most likely to open, for example, 20 to 30 minutes after a meal or a hot drink. If you have a set routine and can feel comfortable and relaxed, this can help encourage the bowel to develop a regular pattern.

 

 

Check your medications

 

See if any are likely to be causing constipation or loose stool. There can be a fine line between helping constipation with laxatives and causing bowel incontinence. People with MS who have bowel incontinence should be assessed for constipation with overflow, possibly exacerbated by laxative use.

 

 

Steps to control leakage and diarrhoea

 

An anti-diarrhoea drug like loperamide (e.g. Imodium) may be effective in treating loose stool. Sometimes codeine phosphate is used. When you are constipated, bowel leakage may stop if you clear the bowel with, for example, a suppository or enema. If not, you may need to combine, with caution and advice, a treatment that empties the bowel and treatment with loperamide. Some people may be taught to wash out the lower bowel. You can also be taught to stimulate local reflexes using a finger (digital stimulation).

 

 

Sphincter exercises for strength and control

 

Squeezing the muscles around the back passage may help strengthen them and may also improve the way you control your muscles. You need to learn to do the exercises the right way and to check from time to time that you are doing them correctly. Once you know how to do them, they should become easy. It takes time for exercise to make muscle stronger. You may need to exercise regularly over several months before muscles gain strength. There are descriptions of sphincter exercises available on the internet. See www.bowelcontrol.org.uk or contact the MS Helpline on 0808 800 8000 if you don’t have access to the internet.

 

 

Re-training – using ‘biofeedback’

 

Biofeedback – a series of sessions with a trained health professional – may help you to strengthen your anal muscles and better regulate your bowel. Sessions will vary, depending on the practitioner. Biofeedback can help by showing you on a computer screen what your muscles are doing, so that you can learn to link often vague sensations with rectal and anal activity. NHS continence advisers are likely to know where biofeedback sessions are held locally.

 

 

Surgery

 

Surgery may be an option for some people. If there is damage to the sphincter muscles, or if you have prolapse (where the rectum slips out of place and down through the anal sphincter muscles), this can be corrected by surgery. For a few people with severe bowel leakage that cannot be managed any other way, it may be possible to have a stoma operation, bringing the end of the bowel out onto the wall of your abdomen so you can wear a bag to collect the stools. This may be a positive decision for some people. If a stoma has been suggested for you, a stoma care nurse can provide information and answer questions you may have.

 

Compliments of:MS Society, UK

 

 

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Responses

  1. Very useful and informative


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